Vascular Thoracic Outlet Syndrome
- Description/Cause
- Thoracic Outlet Syndrome involves the compression of one or more of three key structures
- The brachial plexus
- The subclavian-axillary artery
- The subclavian-axillary vein
- Neurogenic TOS vs Vascular TOS
- Neurogenic pertains to the posterior structures of the upper aperture of the chest
- Prevalence and Risk Factors
- Sunken chest with shoulders forward was more frequent in women than men
- Occupation where you are required to carry heavy objects in a repetitive, over-the-head manner
- Poor posture/prolonged computer use
- Venous TOS
- Motor vehicle accident
- Congenital Musculoskeletal defect
- Cervical rib
- Absence of Anterior Scalene Muscle
- Arterial TOS
- Congenital Musculoskeletal defect
- Signs and Symptoms
- TOS that is exclusively vascular is very rare
- Unilateral pain in arm, forearm, fingers, and occasionally the shoulder and the back of the neck
- Unilateral numbness along the arm down to the fingers, particularly the last three fingers with any type of abduction
- Paleness, Coldness, Weakness and reduced pulse in the Upper Extremity
- Unilateral Tingling (particularly in the last three fingers)
- "relief position"
- holding the arms down along the body
- lying in dorsal decubitus position with arms along the body
- pulling the elbows back
- Objective and Special Tests
- Adson's Test
- Radial pulse of affected extremity is palpated
- Extremity is extended, externally rotated, and slightly abducted at the shoulder
- Patient inhales deeply while radial pulse is palpated and head is rotated toward the affected upper extremity
- Change in pulse is a positive test
- Costoclavicular Syndrome Test
- Clinician palpates the radial pulse
- Clinician then moves the patient's shoulder inferiorly and posteriorly with elbow extended
- Positive test is absence of pulse
- Abductions of the arms laterally to 90 degrees then continuing to 180 degrees and anterior abduction of the arm to the shoulder level and then continuing over the head
- Pallor of the hands at 180 degrees elevation, then rapidly returning to normal when the arm is brought back down indicates vascular compression of the Subclavian Artery
- Wright Maneuver
- Arm is elevated to 90 degrees, the hand is rotated outward and the head is turned in the opposite direction while the patient takes a deep breath, holding it at inspiration
- Radial pulse weakens or disappears = indicative of TOS
- Doppler Ultrasound Examination
- Probe placed in subclavian area
- Patient actively performs abduction maneuvers to 90 degrees, 135 degrees, and 180 degrees while the flows and pressures in the subclavian artery are measured
- Patient must be sitting up and actively moving the arm to the specified positions
- Chest X-Ray
- Treatments and Interventions
- Surgery
- Transaxillary first rib resection
- Physical Therapy
- Interscapular Stabilization Exercises
- Closed Chain movements that minimize scapular winging events
- Soft tissue of stretching of the shortened pectorals major muscle
- Scar mobilizations
- Patient Education
- Patient Education
- Scapular Position
- minimize stress on denervated serratus anterior muscle and other tissues restraining scapula
References
- Molina JE, D’Cunha J. The vascular component in neurogenic-arterial thoracic outlet syndrome. The International Journal of Angiology : Official Publication of the International College of Angiology, Inc. 2008;17(2):83-87.
- Nitz, A. J., & Nitz, J. A. (2013). VASCULAR THORACIC OUTLET IN A COMPETITIVE SWIMMER: A CASE REPORT. International Journal Of Sports Physical Therapy, 8(1), 74-79.
- Lombara A. Thoracic Outlet Syndrome: Arterial and Venous Forms. CINAHL Rehabilitation Guide [serial online]. September 12, 2014;Available from: Rehabilitation Reference Center, Ipswich, MA. Accessed July 9, 2015.
- Marine, L., Valdes, F., Mertens, R., Kramer, A., Bergoeing, M., & Urbina, J. (2013). Arterial Thoracic Outlet Syndrome: A 32-year experience. Elsevier Clinical Research, 1007-1013.
- Sinha, S., Patterson, B., Ma, J., Holt, P., Thompson, M., Carrell, T., . . . Loosemore, T. (2013). Systematic review and meta-analysis of open surgical and endovascular management of thoracic outlet vascular injuiries. Journal of Vascular Surgery, 57(2), 547-567.e7.
Acknowledgements:
David Funk, Student Physical Therapist at A.T. Still University
Ethan Hunke, Student Physical Therapist at A.T. Still University
Morgan Johnson, Student Physical Therapist at A.T. Still University
Ed Nheiu, Student Physical Therapist at A.T. Still University
Lindsay Walczak, Student Physical Therapist at A.T. Still University
Last edited: July 13, 2015